Medical Review Analyst

Schedule

Full-time: 40hrs/wk

Hours: Monday - Friday, 8am - 4:30pm

Work from home

General Summary

Supports clinical areas throughout the System in charge capture, coding accuracy and revenue management. Maintains the department's chargemaster, in conjunction with revenue management, including setting up charges, updating charges and auditing charges against medical documentation. Conducts reviews of departments to optimize reimbursement for the System while ensuring compliance with applicable laws and regulations.

Duties and Responsibilities

Essential Functions:

• Consults with clinical departments on charge process. Ensures appropriate usage of billing mechanisms and process flow to optimize reimbursement through both coding and charge capture.
• Conducts random reviews comparing medical record documentation to validate charge capture.
• Identifies issues with medical necessity and coding that reduce reimbursement. Works with departments to improve the process.
• Investigates and recommends action steps and works collaboratively with the department to improve processes when control, operational weaknesses and /or compliance issues are found. Performs follow up reviews to ensure action steps were met.
• Ascertains compliance with established policies, plans and procedures as well as external regulations.
• Investigates billing system errors as a result of potentially inappropriate documentation, coding, medical necessity or charging. Follows through with the department to ensure corrective action.
• Investigates payers’ denials and institutes appropriate course of action. Develop process improvement if internal review coincides with payer denials to ensure appropriate reimbursement.
• Works with billing and ancillary departments to resolve billing edits and billing inquiries.
• Works in conjunction with Financial Specialist when submitting for appeals for payer denials or requests for reduction in service.
• Interfaces with physicians, managers and staff in departments to ensure quality work product..
• Enters and/or retrieves data from established computer files using knowledge of various computer software applications.

Common Expectations:

• Maintains established policies and procedures, objectives, quality assessment and safety standards.
• Maintains professional growth and development.
• Provides outstanding service to all customers; fosters teamwork; and practices fiscal responsibility through improvement and innovation.
• Administers/coordinates programs, projects, and/or processes as assigned.

Required for All Jobs:

• Performs other related duties as identified.
• WellSpan Health has adopted and implemented a compliance program to support WellSpan's values and standards for professionalism, integrity, and ethics. Expected to support and meet the values and standards of the organization and the performance expectations of the job, the department, and the compliance program.
• WellSpan Health has adopted and implemented a privacy program to safeguard the patient information and the business and operational information of the organization. Expected to support and meet the values and standards of the organization to safeguard patient and business/operational information.

The above statements are intended to describe the general nature and level of work being performed. They are not intended to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified.

Physical Demands:

• Standing - Occasionally
• Walking - Occasionally
• Sitting - Frequently
• Reaching - Rarely
• Talking - Frequently
• Hearing - Frequently
• Repetitive Motions - Occasionally
• Eye/Hand/Foot Coordination - Occasionally

Qualifications

Minimum Education:

• High School Diploma or GED Required or
• Associates Degree Preferred or
• Bachelors Degree Preferred

Work Experience:

• 3 years Related experience. Required

Courses and Training:

• Certified Coder Upon Hire Preferred

Knowledge, Skills, and Abilities:

• Excellent written and oral communication skills.
• Basic computer skills.
• Works effectively in a team environment.